James Paget University Hospitals NHS Foundation Trust

11. Ms B complains about the care and treatment her mother (Mrs A) received at the James Paget University Hospitals NHS Foundation Trust (the Trust) between 30 January 2024 and 2 March 2024. Specifically, the Trust:

• did not do enough to provide Mrs A food and nutrition suitable for a patient with diabetes • did not do enough to assist Mrs A at mealtimes with eating and drinking • did not administer pain relief in a timely manner on 24, 25 and 29 February, nor on 1 and 2 March 2024 • put Mrs A on a syringe driver without consent from her or her family • did not ensure Mrs A was administered a safe dose of Midazolam on 1 March 2024 • did not do enough to ensure Mrs A was being repositioned using the right equipment • did not do enough follow the national framework for end of life and palliative care 2029 to ensure Mrs A was discharged after agreeing to do this after meeting with her family on 26 February 2024 • did not provide Mrs A with the emotional and psychological support it says would be provided for EOL patients and families in its SWAN model (included failure to refer to Armed forces advocate) • did not offer Mrs A’s family emotional and psychological support for a patient approaching EOL (Butterfly volunteers/bereavement counselling service)

12. Mrs A declined because her nutritional intake was inadequate and compromised by the lack of assistance she required. The Trust left Mrs A in pain for longer than necessary. Not knowing the Trust had put in place a syringe driver caused her family distress and Mrs A pain. Mrs A was frail. The medication administered via Syringe driver caused Mrs A to become drowsy and her family lost time with her in her last days. Witnessing her being moved without dignity and care was distressing for her and her family. Mrs A wanted to die at home and the family say the Trust did not do enough to ensure she was discharged when it said it would do. The Trusts lack of emotional and psychological support and failure to refer to services that were available EOL patients and families left them unsupported at a difficult time.

13. Ms B wants an independent investigation of her concerns. She wants answers about her mother care and treatment. She wants service improvements if failings are found to ensure patients with comparable needs do not have the same experience.

14. Mrs A was admitted to the Trust on 29 January 2024 with reduced mobility, worsening memory and feeling generally unwell.

15. Mrs A was transferred to a ward in the Trust on 30 January 2024.

16. The Trust diagnosed Mrs A with multiple myeloma and spoke with her family about this on 14 February 2024.

17. On 27 February 2024 the Trust palliative care team visited Mrs A and spoke with her family about a plan for Last Days of Life (End of Life – EOL). This care plan was created and commenced on 28 February 2024.

18. On 2 March 2024 the Trust discharged Mrs A home. She sadly passed away shortly after on the same day.

The Trust did not do enough to provide Mrs A food and nutrition suitable for a patient with diabetes

23. NICE NG28 on management of adults with diabetes, which says:

‘1.3.3 Encourage adults with type 2 diabetes to follow the same healthy eating advice as the general population, which includes: • eating high-fibre, low-glycaemic-index sources of carbohydrate, such as fruit, vegetables, wholegrains and pulses • choosing low-fat dairy products • eating oily fish • controlling their intake of saturated and trans fatty acids’.

24. Our adviser said this means people with diabetes do not require a special menu. They should be encouraged to eat a balanced diet.

25. Our nursing adviser said the food choices the Trust offered to Mrs A were a balanced (normal) diet in line with the NICE guidance above.

26. In summary, we have not found any indications that something has gone wrong here. The Trust provided Mrs A with a diet in line with relevant standards and guidance. Diabetic patients do not receive a separate diet.

The Trust did not do enough to assist Mrs A at mealtimes with eating and drinking

27. The NMC standards says nurses should:

‘5.1: observe, assess and optimise nutrition and hydration status and determine the need for intervention and support 5.2: use contemporary nutritional assessment tool 5.3: assist with feeding and drinking and use appropriate feeding and drinking aids’.

28. Mrs A was elderly and unwell, eating and drinking on her own was difficult. Ms B said the Trust often gave Mrs A food she could not eat without assistance (such as soups, sandwiches, finger food). Ms B said they often found Mrs A with untouched food and drink when they visited her. That must have been concerning for Ms B.

29. The Trust documented Mrs A was at times drowsy or asleep or declining food when delivered. A Trust care planning form records Mrs A needing assistance with nutrition and hydration from 2 February 2024. The Trust started delivering Mrs A’s food on a red tray and jug.

30. Our nurse adviser said ‘the red tray and jug’ is used across NHS trusts to help staff visually identify when a patient needs assistance and the Trust’s first step was in line with what they would expect here.

31. The complaint here is about actual physical assistance at mealtimes and with hydration. We have great difficulty in assessing this as we were not present and cannot say exactly how the Trust did this. We looked at other evidence to determine if there were any indications of failings here.

32. Ward round notes document Trust nurses regularly assessing Mrs A’s needs through observation to determine levels of support. The food and fluid charts document nurses regularly visiting Mrs A and checking her intake. Mrs A was on occasion asleep or not hungry at mealtimes, which may explain why Mrs A’s family sometimes saw untouched food or fluid.

33. We can see from the food charts Trust gave Mrs A mid meal snacks and fortified drinks. The fluid charts document Trust nurses visiting at intervals of one to three hours every day to ensure Mrs A had fluids and record how much she drank. This shows Trust attention was given specifically to Mrs A’s intake and providing support for that.

34. In summary, we recognise the family’s concerns here. We cannot say exactly what assistance the Trust gave Mrs A at every mealtime. There are possible reasons for why her family found untouched food and water.

35. We have seen no indication the Trust’s actions described above were not in line with standards and guidance. It highlighted Mrs A’s need for full assistance (red jug and tray system). Food and fluid charts document nurse regularly visiting Mrs A and paying attention to her intake. We therefore take no further action here.

The Trust did not administer pain relief in a timely manner on 24, 25 and 29 February, nor on 1 and 2 March 2024

36. NICE CG 138 says:

‘1.2.8 If a patient is unable to manage their own pain relief: • do not assume that pain relief is adequate • ask them regularly about pain • assess pain using a pain scale if necessary (e.g. on a scale of 1 to 10) • provide pain relief and adjust as needed.’

37. NICE CKS Analgesia says for managing mild to moderate pain:

• ‘Paracetamol is usually first line-choice for mild-to-moderate pain although depending on the condition causing the pain, a NSAID may be preferable. Change to, or add another agent if the first option is ineffective • Opioids such as codeine, dihydrocodeine, or tramadol may be used for short periods of time for acute moderate pain where first-line options have not been effective.’

38. Ms B said despite telling the Trust Mrs A was in pain its response was inadequate or slow. We were sorry to learn nurses did not respond as quickly as Mrs A’s family expected when she presented in uncontrolled pain. This must have been distressing for Mrs A and her family. Despite this we can see Mrs A was not without pain relief for any significant period of time.

39. Mrs A’s clinical records show the Trust had a pain management care plan in place from 13 February 2024, highlighting Mrs A was on regular daily analgesia (oxycodone – a fast-acting strong opioid administered for severe pain). The Trust also gave Mrs A paracetamol from 18 February 2023 as required.

40. On 24 February 2024 the Trust documented Mrs A’s pain score was ‘3’ that morning, indicating mild pain. The Trust continued Mrs A on her regular oxycodone morning and evening. The Trust assessed Mrs A’s pain being ‘3’ that evening. A pain score of ‘3’ indicates mild pain and the Trust was already giving Mrs A analgesia used to treat severe pain.

41. On 25 February 2024 the Trust documented Mrs A being in no pain. It reviewed her pain on four separate occasions that day. Our nurse adviser said this indicated her pain was being controlled with her regular pain relief.

42. On 29 February 2024 the Trust documented on Mrs A’s pain score as being between ‘3’ and ‘4’ indicating mild to moderate pain. The Trust began using a syringe driver to assist in delivering pain relief to Mrs A. Syringe drivers are small, portable, battery-operated devices which deliver medicines continuously over a given period, which in this case was 24 hours. The devices may be used at any time in a patient’s care pathway. In this instance it was to control pain symptoms.

43. The Trust notes documented Mrs A being in severe pain (though pain scores suggest Mrs A’s pain was mild to moderate) and it started the syringe driver at 2pm. Mrs A was given the prescribed anticipatory medications. The syringe driver was stopped at 2pm on 1 March 2024.

44. The Trust also gave her morphine sulphate (an opioid analgesic used to treat severe pain). Pain scores thereafter were documented as between no pain ‘0’ and mild pain ‘3’ between 1 March and 2 March 2024.

45. The Trust gave Mrs A analgesia for treating severe pain throughout her admission and she was not without pain relief on any occasion we looked at. We have seen no indication the Trust failed to provide pain relief in line with NICE guidance. It assessed and monitored Mrs A using appropriate tools and gave her pain relief for her documented levels of pain.

46. We were sorry to hear Mrs A remained in pain at times.

The Trust put Mrs A on a syringe driver without consent from her or her family on 29 February 2024

47. The NMC code says, nurses should:

‘4.1balance the need to act in the best interests of people at all times with the requirement to respect a person’s right to accept or refuse treatment.

4.2 make sure that you get properly informed consent and document it before carrying out any action 4.3 keep to all relevant laws about mental capacity that apply in the country in which you are practising, and make sure that the rights and best interests of those who lack capacity are still at the centre of the decision-making process.’

48. The Trust’s consent form says ‘the health professional must consult with those close to the patient unless you have good reason to believe that the patient would not have wished a particular individual consulted, or unless the urgency of their situation prevents this’. The consent form says ‘that treatment can lawfully be provided if it is in the best interest of this patient to receive it’.

49. A syringe driver is a device used when a patient is unable to take medications orally and needs a regular infusion to control symptoms, commonly used in palliative care when anticipatory medications are required. These are medications prescribed in advance for patients with terminal illnesses to manage potential, distressing symptoms promptly.

50. The Trust response says there was no evidence of Mrs A’s family being informed the syringe driver was about to be commenced and there was no documented reason for why the family was not updated. The Trust review indicated the decision to commence the syringe driver was taken in Mrs A’s best interest as there were indications, she was in uncontrolled pain.

51. Clearly the guidance above say families should be consulted or informed of proposed treatment if a patient lacks capacity unless specific circumstances dictate the treatment provided is in the best interest of the patient.

52. We looked at what the Trust has done after acknowledging its failing here.

53. Ms B wants answers and service improvement. The NHS Complaint standards says ‘An effective complaint handling system enables staff to give a fair and balanced account of what happened and the conclusions they have reached. Organisations openly identify instances when things have gone wrong, or where services have had an unfair impact, and take responsibility for these. They make sure staff can offer a range of ways to put things right for the individual. Staff also look at what action will be taken to learn from the experience to continuously improve services and help support staff’.

54. The Trust provided a review of the incident and spoke with Ms B. The Trust said it focussed on syringe driver training and anticipatory prescribing. It said its Palliative Care Team had provided bespoke training to the ward team that had been responsible for Mrs A’s care. It said Trust policy was nurses should attend training every two years.

55. The Trust it was developing a 7-day handover briefing for all nursing and medical staff for the initiation of syringe driver and prescribing using a EEMMA system:

• Evaluate impact of symptoms on patient and family/carer • Explain before starting treatment what is going on to patient and family/carer • Manage the correctable including using non-drug options • Monitor impact of treatment frequently and adjust accordingly • Attention to detail, do not make assumptions and actively listen to patient (or non-verbal clues) and family/carer.

56. The Trust said it had set up a ‘Task and finish group’ for syringe driver education and pain assessment documentation, to improve the syringe driver training programme and aligning pain assessment documentation.

57. The Trust said it had also considered pain assessment. All nurses on the ward where Mrs A received care would undertake bespoke training on pain management action and escalation by the Specialist Pain Nurses and Ward Manager.

58. The Trust said it had made clear only those authorized to sign prescriptions can transcribe them. Reducing the scope for error here.

59. The Trust provided Ms B with a learning timeline and action plan.

60. Ms B should be reassured her complaint here has led to service improvement she said she wanted, which should mean this does not happen again. The Trust response is in line with what we would expect for a failing of this nature and with the NHS Complaints Standards framework we referenced above, and for these reasons we will take no further action here.

The Trust did not ensure Mrs A was administered a safe dose of Midazolam on 1 March 2024

61. Midazolam is used for management of palliative sedation and terminal restlessness.

62. About the prescribed dose of midazolam. The PANG Guideline on ‘Terminal Agitation’ is relevant. It says:

‘The following drugs may be useful. In low doses these can have an anxiolytic effect [reducing anxiety] and will not necessarily be significantly sedating but it is important to explain to patients (if possible) and those important to them the reason for initiating these drugs.

‘First line drugs • Midazolam: usually started as 2.5-5mg hourly prn subcutaneously and depending on response maintained with 10-60mg/24 hours CSCI (higher doses may be used but often a combination with other drugs may be more effective) • Haloperidol: Commonly started as 0.5-1mg hourly prn and maintained with 1.5-5mg/24 hours CSCI but higher doses are also used.’

63. The Trust documents on its Syringe Driver infusion prescription chart the following medications were to be administered for release over 24 hours via the syringe driver - midazolam 2.5mg- 5mg.

64. Mrs A said the Trust did not then check this as it should have.

65. The Trust records show nurses conducted syringe driver checks on 29 February 2024 at 2.00pm, 5.20pm, 10.10pm, and on 1 March 2024 at 02.45am, 6.55am and 10.45am.

66. We are satisfied the Trust prescribed midazolam in a dose in line with the PANG guideline above. We have no standards about the checks. Ms B says the Trust should have checked the syringe driver every four hours and the documented evidence we have seen shows this is what the Trust broadly did. For these reasons we will take no further action here.

The Trust did not do enough to ensure Mrs A was being repositioned using the right equipment (a blue slide sheet)

67. NICE QS89, says on repositioning:

• ‘A lack of mobility and sensation are risk factors for developing pressure ulcers. If a person is unable to reposition themselves, health and social care professionals should help them to change their position, to prevent the development of pressure ulcers. For some people, repositioning equipment may be needed. The frequency of repositioning should be appropriate for the individual and their wishes and needs. For safety reasons, repositioning is recommended at least every 6 hours for adults at risk, and every 4 hours for adults at high risk’.

68. Ms B told us she witnessed on 18 February 2024 Trust nurses repositioning her mother in an undignified way. She said the Trust nurses did not use the blue slide sheet there for that purpose and she fears the Trust were regularly doing this.

69. The Trust used the ‘Waterlow Assessment tool’ (used to assess a patient’s mobility and skin type/visual risk factors). It did this on 31 January 2024 and then 7, 15, 24 and 29 February 2024.

70. The Trust documents Mrs A as being bed bound but having no pressure ulcers. The Trust assessed Mrs A’s need for equipment to be repositioned regularly and only indicated she required assistance. The Trust assessed Mrs A at low risk at each assessment.

71. Our nurse adviser looked at the Trust moving and care handling plans and said there was no indication Mrs A needed any equipment to ‘roll/reposition in bed’. The Trust care planning documents records ‘2 hourly repositioning being in place’. This is in line with the guidance above. The Trust was regularly repositioning Mrs A but we do not know how it was doing this and if it was using blue slide sheets each time.

72. Ms B says the Trust falsified repositioning charts and she disagrees with the clinical assessment made by nurses at the time, which said equipment was not required, and how often Mrs A was being repositioned. We are unable to reconcile her account with the evidence we have seen in Mrs A’s clinical record.

73. We are unable to say if there was a failing here other than on the one occasion Mrs A’s family told us about.

74. The Trust in its response acknowledged and apologised for Ms B’s concern about staff not using blue slide sheets on that occasion. As a response to this concern, the Trust arranged a Safeguarding Review on the ward and said there was no evidence of staff not adhering to acceptable practice on visits. The Trust said using bed sheets for moving and handling is not a technique which should be used and this is not supported during training or care delivery and staff had been reminded to always use slide sheets going forwards.

75. The Trust documents Mrs A not needing repositioning equipment. Despite this it must have been distressing for Mrs A and her family to witness her being moved in an undignified way when a blue slide sheet was easily available for that purpose. Despite finding no evidence of a failing other than the one we were told of, we are reassured the Trust acknowledged this and provide service improvements. Thios was what Mrs A wanted and we will take no further action here.

The Trust did not do follow the NHS framework for End-of-Life care to ensure Mrs A was discharged sooner than she was after agreeing to do this on 26 February 2024

76. The NHS framework for End-of-Life care says: ‘Ambition One: Each person is seen as an individual I, and the people important to me, have opportunities to have honest, informed and timely conversations and to know that I might die soon. I am asked what matters most to me. Those who care for me know that and work with me to do what’s possible.’

‘Ambition Three: Maximising comfort and wellbeing’ says ‘A comfortable death can help those who are bereaved to adjust to their loss in ways that secure their future health and wellbeing.’

77. The NMC standard ‘Future nurse: standards of proficiency for registered nurses’ says they should:

‘4.18 demonstrate the ability to co-ordinate and undertake the processes and procedures involved in routine planning and management of safe discharge home or transfer of people between care settings’.

78. Ms B says the Trust should have discharged her mother home, as per Mrs A’s wishes, within 48 hours of the Trust agreeing to do so after meeting with Mrs A and her family on 26 February 2024. The Trust are acting in line with the Ambition 1 of the NHS framework. It discussed Mrs A and her family’s needs as she approached end of life.

79. When Ms B asked the Trust abut discharge on each following visit the family were told ‘paperwork had not been done’ and given no further information.

80. On 28 February 2024 a Trust Palliative Care Consultant recorded their prognosis Mrs A had days to live. They recorded discussing Mrs A’s discharge with a package of care. The Trust documents Mrs A’s family saying they wanted to take her home and being able to manage without a package of care. Mrs A’s family are documented as saying if Mrs A deteriorated, they were happy with her staying in hospital.

81. Mrs A required a package of care to be delivered for when discharged home – this would include equipment, district nurse visits to administer medication (anticipatory medications) and carers to deliver other care Mrs A may need.

82. On 29 February 2024 a Trust Occupational Therapist had a further discussion with Mrs A’s family around a package of care at home and preference for place of discharge. It was at this point the Trust had a confirmed place to discharge Mrs A to.

83. The Trust then ordered equipment (new mattress and slide sheets) for delivery on 1 March 2024.

84. The Trust then sent the fast-track discharge paperwork on the morning of 2 March 2024 (Saturday). This is two days after having a confirmed place for discharge and one day after the equipment was delivered . When Ms B asked why this was not sent earlier, the Trust said the nurse responsible had been off all week.

85. Ms B contacted a community team member, who contacted the Trust Palliative Care Team. The Trust said it had contacted the Palliative Care Team to see if they had capacity over the weekend, but it did not and would not until Monday. This upset Ms B who explained the urgency of the matter and reiterated her mothers’ desire to die at home. The Trust apologised at the time. The Trust explained staff were concerned about a discharge without a care package in place.

86. The Trust are acting in line with Ambition 3 of the framework. It is attempting to maximise (the equipment/care package) Mrs A’s comfort and wellbeing for when she is discharged home.

87. Ms B said she would take her mother home and the Trust needed to book transport and ensure District Nurses would visit every two hours to administer medications.

88. The Trust arranged transport and for medications for Mrs A’s family to be taken home. The Trust discharged Mrs A home at 5.30pm on 2 March 2024. This is the same day the Trust sent the discharge paperwork.

89. Our nurse adviser was satisfied the Trust nurses acted in line with the NMVB code in arranging for this discharge.

90. In summary we are satisfied the Trust acted in line with the guidance above in arranging for the discharge. It had open conversations with Mrs A’s family about what matters most and worked with them to do what was possible. The Trust could not discharge Mrs A until it had a confirmed place of discharge, equipment delivered and care package in place to ensure her wellbeing was maximised for when that happened. It was unfortunate the discharge nurse was off which may have delayed discharge paperwork being processed sooner.

91. Ms B should be reassured the Trust has acknowledged it could do better here and apologised. It told Ms B there was a Quality Improvement project, led by a Specialist Palliative Care clinician, underway to reduce preventable delays. The Trust reassured Ms B it had arranged for registered nurses to complete bespoke fast track training with the Complex Discharge Sister.

92. We acknowledge the frustration and upset caused to Mrs A’s family around her discharge. We know this is of little consolation, but we were reassured to see when the urgency of the matter meant Mrs A had hours to live, the Trust supported her family in ensuring Mrs A did get to go home.

The Trust did not provide Mrs A with the emotional and psychological support it says would be provided for end-of-life (EOL) patients and families in its SWAN Model And The Trust did not offer Mrs A’s family emotional and psychological support for a patient approaching EOL (Butterfly volunteers/bereavement counselling service)

93. We looked at these headings of concern together as they both are about Trust emotional and psychological support.

94. It has been difficult for us to define exactly what emotional and psychological support Mrs A and her family wanted or needed. We found nothing documented in Mrs A’s clinical record of her or her family requesting this specifically during her admission. Ms B says the Trusts did not follow pledges it makes in its SWAN model.

95. The Trust SWAN Model is used to support and guide the care of patients and their loved ones during EOL care and afterwards. The SWAN acronym stands for ‘Signs, Words, Actions and Needs’. It includes posters and documentation provided informing patients and families of services offered before and after death – such as access to volunteers (Butterfly Volunteers, Armed Forces Advocates) and chaplaincy services to support dying patients and loved ones, documentation of support on offer (Lewis Hamilton centre), communicating with families about their needs (open visiting, free car parking, food vouchers).

96. The SWAN model also talks about ‘Care and support after death’. It says: • We will provide sensitive and compassionate care to those important to you.

• We will signpost those that matter to you to supportive services such as: Chaplaincy, Primary and Community Care Services, The Robins Bereavement Support Group, Louise Hamilton Centre.

• We will provide a bereavement booklet which contains information to guide individuals on what to do following death.

• We will provide identifiable SWAN resources to enable staff to respond compassionately and promptly to the individual needs of the bereaved. Your experience.

97. We have some evidence of good practice in this area. Mrs A was referred for a Palliative Holistic Needs Assessment with Mrs A and her family on 27 February 2024, who would provide support at the end of life. The referral included psychological support, spiritual support and advanced care planning. This was in line with the SWAN Model around communicating with families and patients about their needs.

98. The Trust documents in the section under ‘Social and spiritual needs of the patient and those Important to them’ Mrs A’s family asking if they can bring her dogs in (we know the Trust facilitated Mrs A’s family to do this). We also see in Mrs A’s clinical record the Trust offered Chaplaincy support in line with SWAN.

99. Notwithstanding this the Trust has accepted it should have communicated its support services better and as Ms B wants service improvement, we go straight to what the Trust has said it will do to provide this.

100. The Trust has apologised and acknowledged Ms B did not feel supported towards the end of Mrs A’s life. It said when the Plan for Last days of life was initiated the Palliative Care Team or ward staff should have informed the family of the services it provides in these areas.

101. It specifically mentions support from its Armed Forces Advocate, Butterfly Volunteers and access to the Louise Hamilton centre. We were reassured to see the Trust held full and frank discussions with Ms B around her concerns,

102. The Trust was sorry staff did not provide details for the Armed Forces Advocate and they should have asked for this information on Mrs A’s admission. Ms B confirmed there were posters for this service on the ward, which sadly she did not see until near the end of her mothers’ admission.

103. The Trust has explained all staff received Armed Forces Advocate role and support awareness training as part of its Mandatory Safeguarding training Package, which staff must complete every three years. MS B’s concern was shared with ward staff to improve their awareness of this service.

104. The Trust said Mrs A was visited by a Butterfly Volunteer on 28 February 2024 for 15 minutes, but it did not capture this. The only evidence of Trust attention to this is in Mrs A’s Palliative Holistic Needs Assessment document where Butterfly Volunteers is highlighted. We therefore cannot say this took place with any certainty.

105. The Trust apologised this was not captured in the records or communicated to Mrs A’s family. To improve this the Trust said it would trial a new sticker to be completed by the Butterfly Volunteer to improve and capture these visits. This sticker would be placed in the appropriate documentation and will ensure families and patients are appropriately supported by Butterfly Volunteers and their involvement is accurately recorded.

106. The Trust said there was no documented evidence of Mrs A’s family being informed they were entitled to free parking, food and drink vouchers. It apologised this was not explained when the Plan for Last Days of Life was initiated as it should have been.

107. The Trust said it is working with community partners to establish a new bereavement service to help patients and families. The Trust have also said it is updating its SWAN information leaflet and website to explain what services it provides in these areas.

108. We could find no reference to care after death within the records. We have seen no documented Trust evidence of Mrs A’s family requesting emotional and psychological support as Mrs A approached end of life and in preparation for or after that.

109. It confirmed in terms of psychological support, the Trust explained this is offered by Palliative Care Team nurses and doctors in partnership with other teams (chaplaincy and Cancer care Navigators). If this has been identified, and we seen no evidence in Mrs A’s clinical record of this need being identified for her family, then the Palliative Care Team will ensure patient is known to its St Elizabeth Hospice service and who can then refer them to their Emotional Wellbeing team who can offer clinics or inp0-atient visits.

110. We are satisfied the Trust actions here are in line with the NHS Complaint standards we referenced earlier in this statement. The Trust acknowledged and apologised for failings. It explained service improvements (updated leaflets/web site/staff being made aware of the failings in Mrs A’s case) should ensure better communication of the available support services with patients and their families. We hope will prevent this happening again in the future. The Trust cannot go back and change Mrs A’s family experience here.

111. As it has already taken steps to improve its service in this regard we will take no further action.

112. In summary, we acknowledge the poor experience Mrs A and her family had during her admission. Mrs A had multiple myeloma and her health deteriorated further during her admission because of her condition. The Trust has fully investigated all of Ms B’s concerns and has provided them with a timeline for actions, learning and service improvements where failings have been identified. We know these do not go far enough for Ms B however we are satisfied the Trust have provided the service improvement Ms B wanted in line with what we would expect.

1. We have carefully considered Ms B’s complaint about the care and treatment her mother (Mrs A) received at the James Paget University Hospitals Trust (the Trust). We are sorry to how Mrs A and her family were affected by her time in hospital. We understand and acknowledge the ongoing difficulties, distress and lack of closure for Mrs A’s family.

2. Patients in the NHS do not have a separate diabetic menu. The nutrition the Trust gave Mrs A during her admission was in line with standards and what we would expect.

3. We acknowledge Ms B’s concerns about finding uneaten meals. We are unable to say what physical assistance the Trust gave Mrs A at mealtimes as we were not present. The Trust highlighted Mrs A’s need for this using a red tray and jug system. We are satisfied the Trust acted in line with standards and guidance in monitoring Mrs A’s intake and providing additional assistance and support when it was needed.

4. We were sorry to hear Mrs A had uncontrolled pain at times. We are satisfied the Trust responded on these occasions in line with relevant standards and guidance and provided strong pain relief.

5. The Trust accepted it should have consulted and informed Mrs A’s family in advance of administering the syringe driver. The Trust has apologised, and informed Mrs A’s family of learning and service improvement it has put in place in this area. This is what Ms B wanted. We are reassured the Trust have taken her concerns seriously and responded in line with what we would expect here.

6. The Trust administered a safe dose of Midazolam in line with relevant standards and guidance.

7. Mrs A’s clinical record shows the Trust regularly repositioned her and assessed the need for equipment to do this in line with standards and guidance. We were sorry to learn Mrs A was repositioned in an undignified manner on 18 February 2024. We have only been made aware of this one occasion. The Trust apologised and said it would remind staff of the importance of using the right equipment when moving patients.

8. The Trust did not discharge Mrs A within 48 hours of agreeing to do so. The Trust acknowledged staff should have sent discharge paperwork sooner and apologised this did not happen. The Trust said it has arranged for registered nurses to complete bespoke fast track training with the Complex Discharge Sister. We are satisfied this provides Ms B the service improvement she seeks and is in line with what we would expect here.

9. The Trust acknowledged it did not do enough to provide the support Mrs A and her family needed at this time in line with its Swan Model. It has put in place measures, including updating bereavement booklets and paperwork and reminding staff of the importance of giving families the correct information at the correct time. We are satisfied this provides Ms B the service improvement she seeks and is in line with what we would expect here.

10. We explain our decision on each section further below.